Variation of CD4 Count and Percentage during Pregnancy and after Delivery: Implications for HAART Initiation in Resource-Limited Settings

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Abstract
We studied whether the use of T-lymphocyte CD4 (CD4) absolute count instead of CD4 percentage could affect the decision process regarding HAART initiation in African HIV-infected pregnant women. A prospective cohort in Abidjan, Côte d'Ivoire before HAART was available. Participating women received a perinatal antiretroviral prophylaxis (zidovudine + single-dose of nevirapine). CD4 count and percentage were measured by flow cytometry at baseline (32 weeks of amenorrhea) and at 1 month after delivery. A signed-rank test was used to compare the distributions of the CD4 absolute count and percentage values. A total of 325 HIV-1-infected pregnant women were included. At baseline, their median CD4 count was 355 cells/mm(3) and the median CD4 percentage was 24.8%; 17.8% of women had a CD4 count <200 cells/mm(3) and 14.8 % had a CD4 percentage <15%. One month after delivery, the median CD4 count was 489 cells/mm(3) (vs. baseline: p < 0.001), the median CD4 percentage was 25.6% (vs. baseline: p = 0.107), 9.5% of women had CD4 count <200 cells/mm(3) (vs. baseline: p < 0.001), and 15.1% of women had a CD4 percentage <15% (vs. baseline: p = 0.823). When combining the CD4 count and the WHO clinical stage, the proportion of women who met the WHO 2006 criteria for initiating HAART was 28.3% at baseline but 17.2% only at 1 month after delivery (p < 0.001). Between the prepregnancy and the postdelivery periods, the CD4 count experienced a significant increase, whereas the CD4 percentage remained unchanged. To accurately target the most appropriate time to start HAART, the CD4 percentage could be more reliable than the absolute count in sub-Saharan African pregnant women.